prolonged post op ileusprolonged post op ileus
TRANSCRIPT
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SIXTH POST GRADUATE COURSESIXTH POST GRADUATE COURSEOF THE BELGIAN SECTION OF COLORECTAL SURGERYOF THE BELGIAN SECTION OF COLORECTAL SURGERY
BSCRSBSCRS
COLORECATAL NIGHTMARES
PROLONGED POST OP ILEUSPROLONGED POST OP ILEUS
J-J Houben
U.L.B.Clinique Bruxelloise de Chirurgie Digestive
Gastrospace.com
Clinique Bruxelloise de Chirurgie Digestive
Site Cavell – [email protected]
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Nothing else butNothing else buta good gas…
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PROLONGED POST OP ILEUS
1. Is it a symptom, a syndrome, a disease, …what else?
2. How to suspect it?
3. How to exclude a collateral disease?
4. How to treat the patient affected by ileus?
5. How to manage the family, the G.P., the nurses….?
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PROLONGED POST OP ILEUS
Symptom, syndrome, disease, …what else?
Cessation of normal intestinal motility
Af SAfter Surgery
U di bl l d d f i i l f diUnpredictable prolonged dysfunction preventing oral feedingand recovery
Median time Recovery of intestinal activity 6 hoursgastric activity 24 hourscolon activity 40 hours
LIMIT: 72 H (BLANLOEIL 2000)LIMIT: 72 H (BLANLOEIL 2000)
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PROLONGED POST OP ILEUS
Symptom, syndrome, disease, …what else?
Median time Recovery of intestinal activity 6 hoursgastric activity 24 hourscolon activity 40 hours
Poorly related to : the type of operationthe lengh g
Related to: PainP i t t di (l th)Pre-existent disease (length)Antibiotics
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PROLONGED POST OP ILEUS
Electrical activity and motility
Increased electrical activity does not always results in increased motility
Intrinsic Myenteric and Submucosal plexuses
Slow waves and Spike potentials
The pattern of electromechanical activity – migration electrical complex
The relaxation induces the contraction (NO,…)
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PROLONGED POST OP ILEUS
EXTRINSEC PATHWAYSEXTRINSEC PATHWAYS
Hormonal control mechanismsHormonal control mechanismsGASTRINSECRETINESECRETINEGLUCAGONCHOLECYSTOKININVIPVIPDOPAMINEMOTILIN
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PROLONGED POST OP ILEUS
Pharmacologic agentsMORPHIN METOCLOPRAMIDEMORPHINLOPERAMIDEPHENOTHIAZINES
METOCLOPRAMIDEALIZAPRIDEEPINEPHRINEPHENOTHIAZINES
COLCHICINEANTIBIOTICS
EPINEPHRINENOREPINEPHRINENALOXONE
ALCOLHOLATROPIN
ERYTHOMYCINEDOMPERIDONENSAINSAI
PROTOXYDE CISAPRIDEHALOGENE
GENERALMEDULLAR
NEOSTIGMINEGASTROGRAFINCHARRIER OIL
PERIDURALCHARRIER OILLOCAL ANESTHESIA
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PROLONGED POST OP ILEUS IS A SYNDROME
PAINPAIN
ANESTHSIA
HYPOVOLEMIA
HYPOTHERMIA
PARIETAL AGRESSION
BACTERIAL REDUCTION DECREASESBOWEL MOVEMENTSILEUS INCREASED BACTERIALOVERGROWTH
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PROLONGED POST OP ILEUS
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PROLONGED POST OP ILEUS
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PROLONGED POST OP ILEUS
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PROLONGED POST OP ILEUS
1. Is it a symptom, a syndrome, a disease, …what else?
2. When to suspect it?
3. How to exclude a collateral disease?
4. How to treat the patient affected by ileus?
5. How to manage the family, the G.P., the nurses….?
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When to suspect a abnormal ileus• AFTER 4 DAYS• Slow installationSlow installation• No or short free interval• Vomiting are rare Nausea ++Vomiting are rare. Nausea ++• Severe discomfort- abdominal tenderness• No peristaltism no fever (except bacterialNo peristaltism, no fever (except bacterial
translocation)• IIIrd space (fluid entrapment)p ( p )• Gastric residue
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PROLONGED POST OP ILEUS
1. Is it a symptom, a syndrome, a disease, …what else?
2. How to suspect it?
3. How to exclude a collateral disease?
4. How to treat the patient affected by ileus?
5. How to manage the family, the G.P., the nurses….?
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PROLONGED POST OP ILEUS
43 Y OLD WOMAN TPN FROM 4 YEARSCROHN DISEASE – SMALL BOWEL RESECTIONPERMANENT INTESTINAL ATONIAPERMANENT INTESTINAL ATONIAREFFERRED FOR ILEOSTOMY
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PROLONGED POST OP ILEUS
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PROLONGED POST OP ILEUS
NO DISTAL SURURE
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PROLONGED POST OP ILEUSCollateral and causal factors
M h i l l i• Mechanical occlusion• Vascular insufficiency
Ab• Abscess• Peritonitis
M t i t i i• Mesenteric tumour invasion• Metabolic causes (Hypokaliemia…)
Di b t• Diabetes• Respiratory insufficiency• …..
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PROLONGED POST OP ILEUSPROLONGED POST OP ILEUSCollateral and causal factors
Radiological aspects
• PAF
• CT SCAN
• ULTRASOUND• ULTRASOUND
• RADIOOPAQUE SERIES
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PROLONGED POST OP ILEUSCollateral and causal factorsC
Radiological aspects
• PAF
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PROLONGED POST OP ILEUSPROLONGED POST OP ILEUSCollateral and causal factors
Radiological aspects
• PAF• CT SCAN (Frager 1995)
• ULTRASOUND
• RADIOOPAQUE SERIESSERIES
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PROLONGED POST OP ILEUSCollateral and causal factorsCollateral and causal factors
Radiological aspects
• PAF• CT SCAN• ULTRASOUND
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PROLONGED POST OP ILEUSCollateral and causal factorsCollateral and causal factors
Radiological aspects
• PAF• CT SCAN• ULTRASOUND• GI SERIES
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PROLONGED POST OP ILEUS
1. Is it a symptom, a syndrome, a disease, …what else?
2. How to suspect it?
3. How to exclude a collateral disease?
4. How to treat the patient affected by ileus?
5. How to manage the family, the G.P., the nurses….?
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PROLONGED POST OP ILEUS
ELECTROLYTE INBALANCE Na+, K+, Ca++, Mg+, Phosphate
BACTERIAL TRANSLOCATION – SEPSIS
DENUTRITION
RESPIRATORY INSUFFISENCY
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PROLONGED POST OP ILEUS
APPROPRIATE WATER AND SALINE ADM
SELECTED ANTIBIOTHERAPY (CRP level)
INTESTINAL DECOMPRESSIONINTESTINAL DECOMPRESSION gastric suctiongastrostomygastrostomy
TENS (EXP)
PHARMACOLOGIC AGENTS
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PROLONGED POST OP ILEUS
Pharmacologic agentsPharmacologic agents
MORPHIN EPINEPHRINEO NLOPERAMIDEPHENOTHIAZINES
NOREPINEPHRINENALOXONE
COLCHICINEANTIBIOTICSALCOLHOL
DOMPERIDONE
ALCOLHOLATROPIN
CISAPRIDEMOTILIN
CISAPRIDENEOSTIGMINEGASTROGRAFIN
ENDORPHIN
GASTROGRAFINCHARRIER OILOCTREOTIDE
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PROLONGED POST OP ILEUS
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PROLONGED POST OP ILEUS
1. Is it a symptom, a syndrome, a disease, …what else?
2. How to suspect it?
3. How to exclude a collateral disease?
4. How to treat the patient affected by ileus?
5. How to manage the family, the G.P., the nurses….?
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THE MANAGEMENT OFTHE MANAGEMENT OF COLLATERALS
• Lack of energy• Lack of hope• Lack of strength• Lack of strength• Lack of confidence• Lack of finances
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THE MANAGEMENT OFTHE MANAGEMENT OF COLLATERALS
• Lack of energy PROTEO CALORIC SUPPORTPSYCHOLOGICAL SUPPORT• Lack of hope
• Lack of strength
PSYCHOLOGICAL SUPPORTDAILY INFORMATIONMONITORINGLack of strength
• Lack of confidencePHYSIOTHERAPYMOBILISATIONCALL FOR CONSULTANCE• Lack of finances CALL FOR CONSULTANCESOCIAL HELP
An the final word……
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PROLONGED POST OP ILEUS IS NOT
A PREEXISTENT DISEASE A RARETYA FATALITYA PSYCHOLOGICAL DISORDERA PSYCHOLOGICAL DISORDER A PERMANENT DISEASEAN INTRACTABLE DISEASEAN INTRACTABLE DISEASEA MISTAKEA FAULT